MedSolutions: Improving Healthcare through Information Access and Streamlined Processes

MedSolutions was looking for a solution to provide members with increased transparency of information, and to support health plan customers in delivering this and other consumer-driven healthcare information.

Commentary by Steve Wise, CIO, MedSolutions

Company Overview

MedSolutions is a leading radiology management company that provides customized, proprietary management of high-tech imaging to a national client base.

Business Challenge

MedSolutions has recently undergone significant growth, which led to a dramatic increase in call center volumes. In addition, the company continuously strives for faster, better ways to work with physicians who request imaging studies, and to streamline the authorization process for them. Furthermore, MedSolutions was looking for a solution to provide members with increased transparency of information, and to support health plan customers in delivering this and other consumer-driven healthcare information. As a result, the organization’s plans included a complete overhaul of its prior authorization and notification request process for imaging studies online.

Solution

To improve service delivery to physicians, support client health plan needs, and proactively manage increased demand on call center staff, MedSolutions executives decided to develop a self-service portal that would enable customers and other users to obtain immediate adjudication of imaging requests, and determine approvals or recommended clinical reviews.

To create the portal, MedSolutions partnered with Collaborative Consulting. The team expanded MedSolutions’ proprietary neural modeling (a competency built in to the existing call center application), enabling the portal to immediately adjudicate most “cases.” The expansion was also designed to automate approvals to physicians’ offices without human interaction.

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Figure 1. The robust application offers “My Portal” functionality to members, providers, imaging centers, and health plans that want to conduct ad hoc reporting and customize services based on personal desires.

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As the project began, Collaborative sent a team of user experience design professionals to MedSolutions. The team studied the organization’s business processes—from customer through call center and interactions with managed care companies—as well as its customer requirements and business rules. After evaluating the environment, Collaborative and MedSolutions technology professionals Web-enabled the process that providers (i.e., physicians) undertake to receive authorization, all the while mirroring the existing call center process to foster consistency.

Next, Collaborative introduced experienced project managers to keep the project on time and within budget. Other Collaborative contributors included a group of technology professionals with specific portal architecture and systems integration expertise, and several data warehouse architects. These experts synchronized three disparate data sources—claims, insurance eligibility, and member-imaging authorizations—making patient imaging information readily available to providers while increasing the portal’s functionality significantly.

Benefits

The robust application offers “My Portal” functionality to members, providers, imaging centers, and health plans that want to conduct ad hoc reporting and customize services based on personal desires. Sophisticated scripting and application business rules support provide comprehensive member redirection to lower-cost, high-quality imaging centers. The portal also allows MedSolutions’ health plan customers to enhance their brand via their own customer- facing Web sites, featuring information from MedSolutions’ back-end databases. Other services are being delivered as the rollout continues. These include eligibility verification, claim status, electronic claims submission, and educational programs.

The self-service portal provides a clean and modern visual environment and a strong design that reflects accuracy, simplicity, timeliness, professionalism, and efficiency. These attributes adhere to MedSolutions’ corporate design standards, as well as to its objectives of higher quality and lower diagnostic imaging costs for customers, and reduced call center volumes. In addition, the portal features an intuitive user interface, and delivers immediate access to imaging authorization status, claims, and provider profile information.

Further, it synchronizes patient claims, eligibility, and member imaging authorization data. For example, by integrating fax and mail technology with online processes, providers receive immediate authorizations for treatment and state regulated letters. For more clinically complex cases, detail clinical information or attached progress notes allow nurses and doctors to process cases efficiently.

From a data perspective, the benefits are abundant. The portal can quickly and easily provide reports to specific internal and external users without deploying software or establishing other means of delivery. Internally, data can be leveraged in numerous ways. For example:

• Marketing and product development teams gain insight into the products and services various customers use most often, those they value most, and services that might potentially add value in the future.
• The medical management team can compare patient profiles among people with similar conditions to determine if physicians order unnecessary tests or treatments.
• The sales team can identify opportunities to cross-sell by comparing demographics, behavioral data, product and service use, and survey information.

Externally, partners can use the portal to leverage data and enhance care. For instance:

• Health plans have access to key radiology utilization and cost data for their members, provider reporting, and a platform for private labeling radiology approval processes. With private labels, they can personalize and offer role-based views of core business functions and information to a variety of audiences.
• Providers have access to clinical guidelines and can review ordering patterns and benchmarks.
• Members have access to their imaging information, allowing them to make informed decisions regarding their treatment, including choosing providers based on quality ratings and out-of-pocket expenses.

The portal’s architecture is leveraged as follows:

• Reusability. A services-based approach to components within the solution’s data layer facilitates the reuse of components by leveraging existing legacy systems, resulting in a consolidated, enterprise data layer.
• Reliability. The asynchronous messaging layer provides a consistent user experience, including the ability to continue to submit authorization requests even during back-end system outages.
• Loose coupling. Loose coupling between the business logic layer and data services insulates the business and presentation logic from database schema changes. This approach facilitates the implementation of a major data quality initiative and a new claims processing system with minimal impact to the self-service portal solution.
• Composite application design. By designing the presentation layer as a granular set of interoperating portlets, business processes and application flow can be tailored for different user experiences, or can be based on specific client requirements.

Thus far, the portal has received widespread approval among medical professionals. In addition, it is streamlining call center volume internally, while its user-centric design and immediate access to radiology management data improves customer relationships. Critical first steps of understanding user needs and critical business functions have also paid off. MedSolutions has realized its adoption goals and recouped costs as a direct result of these critical first steps. As time goes on, patients, imaging facilities, and healthcare benefits administrators will benefit from its functionality, and customer satisfaction will continue to increase.